Health History and Medical Information Mr. M Case Study Paper

Health History and Medical Information Mr. M Case Study Paper

Health History and Medical Information Mr. M Case Study Paper

            `The provided case study demonstrates a 70-year-old male patient, Mr. M in the assisted living facility with rapidly deteriorating health. He has limited physical activity associated with unsteady gait and difficulty ambulating. The patient has a history of hypertension which he manages well with ace inhibitors. He also has a history of status post appendectomy, hypercholesterolemia, and tibia fracture status postsurgical rapid but no signs of complications were reported. The patient is on several medications to manage these conditions. However, he is currently concerned about his rapidly deteriorating health and seek further testing. The purpose of this discussion is to evaluate and diagnose the patient to promote the development of appropriate intervention necessary to promote the patient health and provide support to his family.

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Clinical Manifestations of Mr. M.

            Mr. M. is concerned about his rapidly deteriorating health. He presents with limited physical activity associated with unsteady gait and difficulty ambulating. Additional symptoms provided in the subjective portion of the patient history include memory loss, agitation, and aggressiveness. He reports being fearful and afraid whenever he gets aggressive. He is currently unable to independently go through his daily activities. From the provided objective data, Mr. M BMI indicates that he is overweight. His heart rate and blood pressure are also elevated. White blood cell count and lymphocytes are very high showing signs of infection. His urine is cloudy and positive for moderate amounts of leukocytes. Liver function tests reveal normal results.

Diagnoses and Secondary Diagnoses

            Based on the provided history, the most likely primary medical diagnosis for the patient is Alzheimer’s disease. This is the commonest form of dementia characterized by memory loss in advanced age. The patient claims that he is very forgetful and sometimes he even gets lost and needs help to identify his room within the assisted living facility. The decline in cognitive function as displayed by the patient in addition to memory loss is some of the common indicating signs of Alzheimer’s disease (Na et al., 2020). Additional positive symptoms include agitation and aggression associated with being afraid and fearful.

            The most likely secondary diagnosis for the patient is Urinary Tract Infection. This diagnosis is mainly supported by the patient laboratory findings such as high WBC and Lymphocyte count. The patient urine is also cloudy, with moderate leukocytes. Studies also show that UTIs in the elderly can exacerbate dementia symptoms such as memory loss, agitation, and aggressiveness (Chang et al., 2021). Additional secondary diagnoses include hypertension and hypercholesterolemia as reported in the patient medical history.

Explanation of Expected Abnormalities During Nursing Assessment

When assessing the patient, it is necessary to identify the abnormalities displayed in the patient’s objective data. His lab works and urinalysis results reveal abnormalities for a UTI. For instance, the patient’s WBC is 19.2 (1,000/uL) way higher than the normal range for male adults at 4.5 to 11.0 × 10⁹/L (Roy et al., 2020). His lymphocyte count is also high at 6700 (cells/uL) above the normal range of between 1000 to 4800 cells/uL. Urinalysis results also reveal the presence of leukocytes in the patient’s urine which is a sign of inflammation or infection of the urinary tract. As such, further assessment such as abnormalities in urinary patterns like hesitancy, urgency, or frequency is necessary. Additionally, the patient also presents with signs of multiple mental comorbidities associated with impaired cognitive function, which may result from dementia, depression, delirium, or endocrine derangements. Most of these mental conditions normally result from concurrent disease processes which in the case of this patient is a UTI.

Effects of Health Status on Physical, Psychological, and Emotional Aspects of Patient and Family

            The patient current health status indicates signs of Alzheimer’s disease which might have been triggered by a urinary tract infection, impairing his physiological and physical functioning. For instance, due to Mr. M’s Alzheimer’s condition, he presents with limited physical activity associated with unsteady gait and difficulty ambulating (Na et al., 2020). He is even unable to support independent living and needs help in doing most of his routine daily activities. Psychologically, the patient’s decline in cognitive function can lead to comorbid mental problems such as depression and delirium among others. Emotionally, the patient memory loss to the point that he forgets even his family members can be very frustrating, making him sad. This can also be very overwhelming for the family members leading to a range of emotions like fear, anger, sadness, and frustration.

Interventions for Support

            To promote the health and well-being of the patient, it is necessary to manage all the underlying diseases such as UTIs, to reduce their impact on deteriorating the patient health. Consequently, with the suspected Alzheimer’s disease, the patient will greatly benefit from memory training, physical exercise programs, and mental and social stimulation (Gowan & Roller, 2019). Such interventions will help improve the patient’s cognitive performance and promote his independence. The patient’s family members will also need to be educated on how to help the patient recover. They also need emotional support which will be achieved through support groups and counseling.

Actual or Potential Problems Based on Condition

            The first problem the patient is facing is the presence of a urinary tract infection supported by cloudy urine with leukocytes and high WBC and lymphocyte count. If the patient’s UTI goes untreated, it may lead to additional complications such as renal impairment or sepsis. These two conditions can precipitate acute kidney injury declining the functioning of his kidneys (Gracner et al., 2019). The patient also displays possibilities of Alzheimer’s disease, supported by the patient’s decline in cognitive function causing memory loss, agitation, and aggressiveness. Alzheimer’s disease can lead to dysphagia for both solids and liquids causing dehydration, malnutrition, or aspiration pneumonia.

Conclusion

            The patient in the provided case study is concerned with his rapidly deteriorating health status. From the provided history, the patient is most likely suffering from Alzheimer’s disease which may have been accelerated by his urinary tract infection. He needs to undergo memory training, physical exercise programs, and mental and social stimulation to promote his cognitive function. His family members also need to join a support group for emotional support.

References

Chang, C. W., Juan, Y. S., Yang, Y. H., & Lee, H. Y. (2021). The Relationship Between Lower Urinary Tract Symptoms and Severity of Alzheimer’s Disease. American Journal of Alzheimer’s Disease & Other Dementias®, 36, 1533317521992657. DOI: 10.12779/dnd.2020.19.3.77

Gowan, J., & Roller, L. (2019). Disease state management: Alzheimer’s disease and other common dementias. AJP: The Australian Journal of Pharmacy, 100(1188), 64-75. https://search.informit.org/doi/10.3316/informit.655718596363903

Gracner, T., Sorbero, M., Stone, P. W., Agarwal, M., & Dick, A. W. (2019). Advanced illness among elderly nursing home residents with Alzheimer’s disease and related dementia. Innovation in Aging, 3(Suppl 1), S509. DOI: 10.1093/geroni/igz038.1882

Na, H. R., & Cho, S. T. (2020). Relationship between lower urinary tract dysfunction and dementia. Dementia and Neurocognitive Disorders, 19(3), 77. https://doi.org/10.1177/1533317521992657

Roy, H. A., Nettleton, J., Blain, C., Dalton, C., Farhan, B., Fernandes, A., … & Drake, M. J. (2020). Assessment of patients with lower urinary tract symptoms where an undiagnosed neurological disease is suspected: A report from an International Continence Society consensus working group. Neurourology and Urodynamics, 39(8), 2535-2543. https://doi.org/10.1002/nau.24469

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Health History and Medical Information
Health History
Mr. M., a 70-year-old male, has been living at the assisted living facility where you work. He has no know allergies. He is a nonsmoker and does not use alcohol. Limited physical activity related to difficulty ambulating and unsteady gait. Medical history includes hypertension controlled with ACE inhibitors, hypercholesterolemia, status post appendectomy, and tibial fracture status postsurgical repair with no obvious signs of complications. Current medications include Lisinopril 20mg daily, Lipitor 40mg daily, Ambien 10mg PRN, Xanax 0.5 mg PRN, and ibuprofen 400mg PRN.
Case Scenario
Over the past 2 months, Mr. M. seems to be deteriorating quickly. He is having trouble recalling the names of his family members, remembering his room number, and even repeating what he has just read. He is becoming agitated and aggressive quickly. He appears to be afraid and fearful when he gets aggressive. He has been found wandering at night and will frequently become lost, needing help to get back to his room. Mr. M has become dependent with many ADLs, whereas a few months ago he was fully able to dress, bathe, and feed himself. The assisted living facility is concerned with his rapid decline and has decided to order testing.
Objective Data
1. Temperature: 37.1 degrees C
2. BP 123/78 HR 93 RR 22 Pox 99%
3. Denies pain
4. Height: 69.5 inches; Weight 87 kg
Laboratory Results
1. WBC: 19.2 (1,000/uL)
2. Lymphocytes 6700 (cells/uL)
3. CT Head shows no changes since previous scan
4. Urinalysis positive for moderate amount of leukocytes and cloudy
5. Protein: 7.1 g/dL; AST: 32 U/L; ALT 29 U/L
Critical Thinking Essay
In 750-1,000 words, critically evaluate Mr. M.’s situation. Include the following:
1. Describe the clinical manifestations present in Mr. M.
1. Based on the information presented in the case scenario, discuss what primary and secondary medical diagnoses should be considered for Mr. M. Explain why these should be considered and what data is provided for support.
2. When performing your nursing assessment, discuss what abnormalities would you expect to find and why.
3. Describe the physical, psychological, and emotional effects Mr. M.’s current health status may have on him. Discuss the impact it can have on his family.
4. Discuss what interventions can be put into place to support Mr. M. and his family.
5. Given Mr. M.’s current condition, discuss at least four actual or potential problems he faces. Provide rationale for each.
You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Clinical Manifestations of Mr. M.

5. Excellent

12 points

Subjective and objective clinical manifestations are detailed. The clinical manifestations are accurate and clearly report the observed and perceived signs and symptoms.

4. Good

10.68 points

Subjective and objective clinical manifestations are described. Overall, the clinical manifestations are accurate and reflect observed and perceived signs and symptoms.

3. Satisfactory

9.48 points

Clinical manifestations are summarized. An overview of the general symptoms is presented. Some findings are incomplete.

2. Less Than Satisfactory

9 points

Clinical manifestations are partially presented. There are major omissions and inaccuracies.

1. Unsatisfactory

0 points

Clinical manifestations are omitted.

collapse Diagnoses and Secondary Diagnoses assessment

Diagnoses and Secondary Diagnoses

12 points

Criteria Description

Diagnoses and Secondary Diagnoses

5. Excellent

12 points

A detailed discussion on what primary and secondary medical diagnoses should be considered for Mr. M. is presented. Strong rationale and reliable data are used to explain why the diagnoses are relevant and should be considered.

4. Good

10.68 points

A discussion on what primary and secondary medical diagnoses should be considered for Mr. M. is presented. General rationale and relevant data are used to explain why the diagnoses should be considered. There are minor inaccuracies.

3. Satisfactory

9.48 points

A general discussion on what primary and secondary medical diagnoses should be considered for Mr. M. is presented. There are some inaccuracies. A summary provides some rationale and evidence to explain why the diagnoses are relevant.

2. Less Than Satisfactory

9 points

A partial discussion on what primary and secondary medical diagnoses should be considered for Mr. M. is presented. There are major inaccuracies. Rationale and evidence for the diagnoses are lacking.

1. Unsatisfactory

0 points

A discussion on what primary and secondary medical diagnoses should be considered for Mr. M. is omitted; or, medical diagnoses presented are inaccurate.

collapse Explanation of Expected Abnormalities During Nursing Assessment assessment

Explanation of Expected Abnormalities During Nursing Assessment

18 points

Criteria Description

Explanation of Expected Abnormalities During Nursing Assessment

5. Excellent

18 points

A thorough discussion of abnormalities a nurse would expect to find during a nursing assessment is presented. Strong rationale and evidence are provided for support.

4. Good

16.02 points

A discussion of abnormalities a nurse would expect to find during a nursing assessment is presented. General rationale and evidence are provided for support.

3. Satisfactory

14.22 points

A general discussion on the abnormalities a nurse would expect to find during a nursing assessment is presented. There are minor inaccuracies. Some rationale or evidence is provided for support.

2. Less Than Satisfactory

13.5 points

An incomplete summary of some abnormalities a nurse would expect to find during a nursing assessment is presented. There are inaccuracies. No rationale or evidence is provided for support.

1. Unsatisfactory

0 points

A discussion of what abnormalities a nurse would expect to find during a nursing assessment is omitted; or, the expected findings are not relevant for the patient or his health status.

collapse Effects of Health Status on Physical, Psychological, and Emotional Aspects of Patient and Family assessment

Effects of Health Status on Physical, Psychological, and Emotional Aspects of Patient and Family

18 points

Criteria Description

Effects of Health Status on Physical, Psychological, and Emotional Aspects of Patient and Family

5. Excellent

18 points

A thorough discussion of the effects of the health status on the physical, psychological, and emotional aspects of the patient, and the impact the health status has on the family, is presented. Strong support for the discussion is provided.

4. Good

16.02 points

A discussion of the effects of the health status on the physical, psychological, and emotional aspects of the patient, and the impact the health status has on the family, is presented. Support for the discussion is provided.

3. Satisfactory

14.22 points

The effects of the health status on the physical, psychological, and emotional aspects of the patient, and the impact the health status has on the family, are summarized. Overall, the described effects on the patient and impact to the family are relevant. Some support for the discussion is provided.

2. Less Than Satisfactory

13.5 points

The effects of the health status on the physical, psychological, and emotional aspects of the patient, and the impact the health status has on the family, are partially summarized. The effects presented are questionable, and support for the discussion is not provided.

1. Unsatisfactory

0 points

The effects of the health status on the physical, psychological, and emotional aspects of the patent, and the impact the health status has on the family, are omitted.

collapse Interventions for Support assessment

Interventions for Support

18 points

Criteria Description

Interventions for Support

5. Excellent

18 points

All relevant interventions that can be put into place to support Mr. M. and his family are thoroughly discussed.

4. Good

16.02 points

Key interventions that can be put into place to support Mr. M. and his family are discussed. Some detail is needed for clarity.

3. Satisfactory

14.22 points

Some interventions that can be put into place to support Mr. M. and his family are summarized. There are minor inaccuracies.

2. Less Than Satisfactory

13.5 points

Some interventions that can be put into place to support Mr. M. and his family are partially presented. More information is required.

1. Unsatisfactory

0 points

Interventions that can be put into place to support Mr. M. and his family are omitted.

collapse Actual or Potential Problems Based on Condition assessment

Actual or Potential Problems Based on Condition

18 points

Criteria Description

Actual or Potential Problems Based on Condition

5. Excellent

18 points

Four or more actual or potential problems faced by the patient are thoroughly discussed. The posed problems are clearly related to his condition. Strong rationale is provided and supports the discussion.

4. Good

16.02 points

Four or more actual or potential problems faced by the patient are discussed. The posed problems are relevant to his condition. Rationale provided generally supports the discussion.

3. Satisfactory

14.22 points

At least four actual or potential problems faced by the patient are summarized. The posed problems are generally relevant to his condition. There are minor inaccuracies. Some information or rationale is needed.

2. Less Than Satisfactory

13.5 points

Three actual or potential problems faced by the patient are partially presented. It is unclear how some of the posed problems are relevant to his condition. There are inaccuracies.

1. Unsatisfactory

0 points

Fewer than three actual or potential problems faced by the patient are presented. The problems posed are not relevant to his condition.

collapse Thesis Development and Purpose assessment

Thesis Development and Purpose

6 points

Criteria Description

Thesis Development and Purpose

5. Excellent

6 points

Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.

4. Good

5.34 points

Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.

3. Satisfactory

4.74 points

Thesis is apparent and appropriate to purpose.

2. Less Than Satisfactory

4.5 points

Thesis is insufficiently developed or vague. Purpose is not clear.

1. Unsatisfactory

0 points

Paper lacks any discernible overall purpose or organizing claim.

collapse Argument Logic and Construction assessment

Argument Logic and Construction

6 points

Criteria Description

Argument Logic and Construction

5. Excellent

6 points

Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.

4. Good

5.34 points

Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.

3. Satisfactory

4.74 points

Argument is orderly but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.

2. Less Than Satisfactory

4.5 points

Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.

1. Unsatisfactory

0 points

Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.

collapse Mechanics of Writing (includes spelling, punctuation, grammar, language use) assessment

Mechanics of Writing (includes spelling, punctuation, grammar, language use)

6 points

Criteria Description

Mechanics of Writing (includes spelling, punctuation, grammar, language use)

5. Excellent

6 points

Writer is clearly in command of standard, written, academic English.

4. Good

5.34 points

Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used.

3. Satisfactory

4.74 points

Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.

2. Less Than Satisfactory

4.5 points

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, or word choice are present.

1. Unsatisfactory

0 points

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.

collapse Paper Format (use of appropriate style for the major and assignment) assessment

Paper Format (use of appropriate style for the major and assignment)

2.4 points

Criteria Description

Paper Format (use of appropriate style for the major and assignment)

5. Excellent

2.4 points

All format elements are correct.

4. Good

2.14 points

Appropriate template is fully used. There are virtually no errors in formatting style.

3. Satisfactory

1.9 points

Appropriate template is used. Formatting is correct, although some minor errors may be present.

2. Less Than Satisfactory

1.8 points

Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent.

1. Unsatisfactory

0 points

Template is not used appropriately, or documentation format is rarely followed correctly.

collapse Documentation of Sources assessment

Documentation of Sources

3.6 points

Criteria Description

Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)

5. Excellent

3.6 points

Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.

4. Good

3.2 points

Sources are documented, as appropriate to assignment and style, and format is mostly correct.

3. Satisfactory

2.84 points

Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.

2. Less Than Satisfactory

2.7 points

Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.

1. Unsatisfactory

0 points

Sources are not documented.